My patient at a pain clinic on a military base in Virginia carried the deep wounds of war on his face. Not physical scars, but a sallow, slack complexion and a hollow-eyed look of exhaustion and defeat. A veteran of the war in Afghanistan, he had long been suffering from anxiety, depression, and other complications of PTSD, although his presenting complaint was back pain.
The patient, whom I’ll call Sergeant Carlson, had filled out a personal health inventory (PHI) that I use for all my complex patients, a process used by the Veterans Health Administration that I find incredibly useful in starting to build a healing relationship and guide them on a recovery journey. The PHI included the question: “What matters most to you in your life?”
“My cat and my wife,” Sgt. Carlson had written — in that order. “Tell me more,” I said.
“My cat is my friend. I had him for ten years, and he’s my companion during the day. He knows when I’m in trouble and comes to calm me down,” he said. “My wife is my best friend, and she helps me get through the nights, but she’s working most days.”
This conversation, which altered the course of his treatment, might never have occurred if I had not changed how I conduct my practice to embrace “whole person care.” I had begun talking and listening to my patients differently and then asking questions much broader than those that just focused on the chief complaint.
I was seeking to explore the issues of Sgt. Carlson’s life that lay far beyond the walls of my office, but that clearly contributed to his illness. He did not need a change in his meds. Instead, he needed a full partner who could help him find his way on the sometimes bewildering journey from illness to wellness.
My lifelong quest to become a healer — over 40 years as a family physician, scientist, and researcher with the National Institutes of Health, the World Health Organization, the Walter Reed Army Institute of Research, and the Department of Defense — has led me to conclude that the best way to forge the strongest, most effective doctor-patient partnership is not to limit my questions to “What’s the matter with you?” in an attempt to make a medical diagnosis. Instead, we must attempt to get to the root of our patients’ health and well-being goals by asking: “What matters to you in your life?”
Like countless physicians, I struggled with frustration and burnout over the years. I needed to connect more deeply with my patients, but I had little training, time, or support to do that. So, I restructured my office visits to reframe the patient’s experience (and mine) from one focused exclusively on diagnosing and treating disease to one that personalizes care and emphasizes prevention, health promotion, and self-care. I shifted from focusing only on treatment to learning how to support the process of healing. This shift brought me back to the heart of why I became a doctor in the first place.
As new doctors, we were trained to write a SOAP note (Subjective, Objective, Assessment, and Plan) to chart the course of a patient’s condition and treatment. But research shows that medical treatment itself accounts for only about 20 percent of health and healing. Nearly 80 percent comes from other factors rarely addressed by our system. These are the emotional and mental health, behavioral and lifestyle practices, and the social and economic environment in which a person lives — factors that are rarely captured in the SOAP note.
I take a “whole-person care” approach with my patients. This includes having patients complete a health questionnaire about a patient’s social determinants of health. The insights I gain from this questionnaire and interview with my patients give me a much more complete understanding of their lives, putting the patient front and center in creating a care plan. Best of all, it brings out the patient’s intuition about what they need most. This allows me to offer them whole-person care that combines conventional medicine with evidence-based complementary modalities such as health coaching, group visits, nutritional counseling, acupuncture, yoga, meditation, therapeutic massage, stress reduction, and other non-drug approaches.
In Sergeant Carlson’s case, our visit turned him in a new direction that involved personal journaling, peer-group counseling, and more. His path remains difficult, but he was infused with new energy and motivation. Learning from patients like him, I have developed a more rewarding practice that relies less on pills and procedures and more on listening and healing.
It is also important to understand that this is not pie-in-the-sky. The Veterans Administration, for example, showed remarkable results in shifting its care model from a traditional disease-based transactional system to a team-based, person-centered care model that addresses patients’ physical, emotional and social well-being. In their four-year pilot program with 130,000 veterans at 18 sites, the VA reported improved outcomes, patient experience ratings, and a significant savings of 20 percent, or nearly $4,500 annually per veteran.
And while the VA is looking for large-scale change, the opportunity for moving toward whole-person care is available at all levels of care. While health is determined largely by factors outside the health care system, we can still provide the tools, the teams, and, most importantly, the language to guide patients on their path to healing. It starts by truly putting the patient at the center of it all, asking them what matters, and supporting them in addressing their determinants of health.
Wayne B. Jonas is a family physician.
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